Provider Demographics
NPI:1740966829
Name:WALLACE, ALEXANDRA BALTAZAR (PA-C)
Entity type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:BALTAZAR
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PA-C
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Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:507 KIMBERTON RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIXVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19460-4745
Mailing Address - Country:US
Mailing Address - Phone:610-243-9117
Mailing Address - Fax:
Practice Address - Street 1:507 KIMBERTON RD
Practice Address - Street 2:
Practice Address - City:PHOENIXVILLE
Practice Address - State:PA
Practice Address - Zip Code:19460-4745
Practice Address - Country:US
Practice Address - Phone:610-243-9117
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-23
Last Update Date:2025-05-31
Deactivation Date:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant